Exploring barriers to and facilitators of malaria prevention practices: a photovoice study with rural communities at risk to Plasmodium knowlesi malaria in Sabah, Malaysia

Background The control of Plasmodium knowlesi malaria remains challenging due to the presence of macaque monkeys and predominantly outdoor-biting Anopheles mosquitoes around human settlements. This study aims to explore the barriers and facilitators related to prevention of mosquito bites among rural communities living in Sabah, Malaysia using the participatory visual method, photovoice. Methods From January through June 2022, 26 participants were recruited from four villages in Kudat, Sabah, using purposive sampling. Participants were male and female villagers, aged > 18 years old. After photovoice training in the villages, participants documented facilitators of and barriers related to avoiding mosquito bites using their own smartphone cameras, and provided narratives for their photos. Twelve Focus Group Discussions (FGDs) sessions in three rounds were held to share and discuss the photos, and to address challenges to the avoidance of mosquito bites. All discussions were conducted in the Sabah Malay dialect, and were video and audio recorded, transcribed, and analyzed using reflexive thematic analysis. The Ideation Model, a meta-theoretical model of behaviour change, underpinned this study. Results The most common types of barriers identified by participants included (I) intrapersonal factors such as low perceived threat of malaria, (II) livelihood and lifestyle activities consisting of the local economy and socio-cultural activities, and (III) physical and social environment. The facilitators were categorized into (I) intrapersonal reasons, including having the opportunity to stay indoors, especially women who are housewives, (II) social support by the households, neaighbours and healthcare workers, and (III) support from healthcare services and malaria awareness program. Participants emphasized the importance of stakeholder's support in implementing feasible and affordable approaches to P. knowlesi malaria control. Conclusion Results provided insights regarding the challenges to preventing P. knowlesi malaria in rural Kudat, Sabah. The participation of communities in research was valuable in expanding knowledge of local challenges and highlighting possible ways to overcome barriers. These findings may be used to improve strategies for zoonotic malaria control, which is critical for advancing social change and minimizing health disparities in malaria prevention. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-023-16173-x.

Additional File 3: Thematic analysis with deductive-inductive approach.
Themes (deductive approach) Themes derived from the Delphi study and its definition FGD contents (with codes) Barriers Intrapersonal factors 1. Demographic factor: Demographic factors are age, gender, occupation, education, and household income that possibly influence malaria preventive behavior.
2. Cognitive factor: Cognitive factors describe how the mental process acquires knowledge and understanding about something through thought, experience, reasoning and language. This includes the attitude, ability or inability to identify risky behaviors to malaria, perceive threat and vulnerability towards the malaria infection and subjective norms (perceive others' thinking), and. For example: How does a person/community believe a person can get the malaria infection or how does wearing long pants and shirts could protect a person from getting malaria?
3.Knowledge: Knowledge is a justified belief (e.g through awareness programme, reading, education, health promotion) that describes what the individual and community understand about the disease, transmission, activities at risk, and protective measures, including wearing protective clothing when performing outdoor work and putting on bednets during sleep.
"Relaxing at the verandah after dinner while using the smartphone." [Farmer,32 years  mosquitoes, natural reservoir (e.g. Macaque monkeys), forests, plantation, farming land that serve as suitable condition for malaria transmission. 2. Social environment: As defined by Barret and Casper (2001) as "the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact" The components include built infrastructure; industrial and occupational structure; labor markets; social and economic processes; wealth; social, human,and health services; power relations; government; race relations; social inequality; cultural practices; the arts; religious institutions and practices; and beliefs about place and community; for example, human work/activities including timing or duration of work/activities that exposed them to infective mosquito bites, travelling duration to work/activities that poses similar exposure to malaria, frequency of going to the work/activities (e.g in the jungle) and details on agricultural or outdoor activities.
3. The influence of community value and social norms (nonverbal rules of behavior that are acceptable in a group or community). For example, how do the community members support each other by advising to avoid outdoor activities during nighttime, due to the risk of mosquito bites? 4.Socioeconomic factors that include details on their source of income, e.g location, timing, effect of weather, environment and others that could influence their malaria preventive behavior. 2. Cognitive factor: Cognitive factors describe how the mental process acquires knowledge and understanding about something through thought, experience, reasoning and language. This includes the attitude, ability, or inability to identify risky behaviors to malaria, perceive threat and vulnerability towards the malaria infection and subjective norms (perceive others' thinking), and. For example: How does a person/community believe a person can get the malaria infection or how does wearing long pants and shirts could protect a person from getting malaria? 3.Knowledge: Knowledge is a justified belief (e.g through awareness programme, reading, education, and health promotion) that describes what the individual and community understand about the disease, transmission, atrisk activities, and protective measures, including wearing protective clothing when performing outdoor work and putting on bednets during sleep. Social support describes the interpersonal interaction or support from the surrounding people, governance or other sectors, for example, by providing accessibility to mosquitoavoiding tools, or any effort or activities that helps to avoid mosquito.
"At 9 o'clock at night, I iron the school uniforms (of my children) in preparation for school tomorrow." [Gardener,33 years old,Kg. Tagumamal Darat] "Normally, the wives stay at home after sunset to take care of the house and children. Manduri] (lifestyle, activities, social norm, both gender) Drivers Theme 3: Support from healthcare services and malaria awareness program Support from healthcare services and malaria awareness programs refers to the role of healthcare services, primarily the healthcare clinic and hospital in the study area. This theme also includes malaria-focused awareness programs in supporting individuals and communities in their efforts to prevent and control malaria, and empowering community members to prevent malaria . This theme explores the availability, accessibility, and quality of healthcare services and the effectiveness of malaria awareness programs in promoting preventive behaviors and raising awareness about malaria within the local population. In comparison to the 'social support' theme, this theme investigates how the healthcare providers engage with the local community, including the support and guidance in adopting preventive measures. It also assesses the impact of malaria awareness programs on individuals' knowledge, attitudes, and practices related to malaria prevention.